22956 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildin ha ect Idmtlfkatlm PMWT NO.
RulldDAOd?� 22956
rete _ y5 CA b me:
.
o�o�', 0QJ CITY OF CUPERTINO-BUILDING DMSION
• mvad
or'eNsme: IJc.No: APPLICATION /PERMIT 6
BUIL.DINGELF.CIIUCA MP BINGMECHANKAL CATEGORY CONTROL
Areed/Engirmer. Lk.No:
Q ELECTRIC PERMIT FEE rBUILDING PERMIT INFO
Address POWTISSUANCE ❑ ❑ �7c1 ❑
LICENSED CONTRACTORS DECLARATION
I herebyafflrm that l em Itimeed under provisions&Clupter9(eommeo APPLIANCES-RESIDENTIAL )OBD RIPFION
Ing with Section 7000)of Divldm3 ofthe BusireumdPrefeedonsCode,and ory
lkeree V In full fora and effeci. PANELS 11
Liana Class Lk I ��/ `-
Date Conmad.1 —UP TO 2DOAhff'S
ARCHITTCPS DECLARATION 2014000AMPS
pQ+{M�yz I undemaM eny plans ebaB be used a public record& OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
E L LlceuM Profesbnal SIGNSELECTRICAL
OWNER-BNLDER DECLARATION SPECIALCIXCLIIT/MISC
7 i'o+� Ihereby afBrnn that l am exempt from the Contractor's Llcerue Law for the
F�^❑ following maser.(Sedlm 7(315,Buelness end Pmfssbne Code:My dty or
� cwntywhkhrequbesapeodttommtaud,eter, pmve,der h,ormpalr TE.IP.MEIFR OR POLE WST.
ed y� anysbumrrt prbrty its fswarce,ebo requlresthmappBant(ee each permitro
POWER ER DEVILS
KFq K
file a signed easement that he is lkrr purwnt to the provlsiom of the
Contractor.Lke.Law(Chapmr 9(mmmendng with Section 7000).f Divi- SWD. NG POOL,ELECTRIC
of slo,3ofthe Business and ProfmlomCode)orthrt he is exempt therefemaM VALUATION
the beale for the alleged exemption. My Wdallon of Sed1On I'MIS by any
7� 81 appllant fore permit sub)octs the applicant toot civil .by dnd mom than OUTIXSSWITCHES FIXTURES
c. $ five hundred dollars(SSM.
❑I,as owner of the property,or my employs,with wages as their aob NEW RE9DENIIALELFI IR SQ}7. STORIES TYPECONSIRUCTIM
�7 canpewHon,wlll do the week and the strudum b not(tended or offered for
Dsale(sec.7014,Buelress est Pmfm ic.Code:The Gerstmann.u..Law
$ does net apply to m owner of property who builds or lmpmvn thereon,and
FS^ who doessuchworkMmeelforthrough wownemployeee,pmvidcd that such OCC.CROUP RES UNTTS
Improvemmw are nd intended oroffered fee sale.If,however,thebullding or TOTAL
bnpmwmm lasaidwthinomyearofceeiple Ntheowner-buMerwBlhive
t eden of p,wing the he dm
out build or improve fee purpoea of sale). QTY. PLUMBING PERMIT FEE
�
w
[u owner of the property,am evcfvely conix rang with licensed FLOOD ZONE APN
mnirertmato mmfnud she pmjrd(See 7W4,Buelnm and Prdesbv Cad,. PERMITL'S[JANCE
15—
The Contrsciors Lkerme Law don not apply tom owner IX property who ALS-DRAW 4 VENT-WATTR(EM
bu Bole c9atEact r Imprwa thereon, and who mMrsde fee loch p(ojede with
L.JItnne. mpt under ScttotheCmtrador'aLloenaelrw. BACK FLOW PROTECT..DEVICE FEE
OUSUMMARY
IDEH
LJ I am nempt under Sec B k P C for this maven
S
DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y_ N_Owner Date RFLEPTI
WORKMAN COMP E395ATZONree of
pp(.NRES I'ER TRAP 5a IOOLTAX Y_ N_
❑1 hereby affirm Co I have• lMR of amdif to self-insWytheurt,T • RECEPTY
adlDabC.Worken'Compematlmlwrsnaeeacertified ropytherroff5ec. GAS FA.SYSTEM.1 INCA OUTLETS PARK FEE Y_ N
3800,Lab C.)
P on GAS EA.SYSI'FM-0VER 4(EA) DING DIPT Y
ny BUILDING DIVISION i510N FEES
m afdifled copy b heburnished, GREASE/IN'DUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Crafted ropy ts/lieded with with the city impectbn division.
CERTIFICATE OF EXFAIPTION FR WORKERS GREASE TRAP PAID
COMP ION( E SEW'FR-SAM'EARY-STORM EA.70(BIT. Date Recel t#
OTta atoll coon lot d e molt (orore hundred dollve
(glm)ee wATRHFATFRW/v /E.FICTR ENERGY FEE Y N
I ylhrtdthe ser once (o hlchtwpemttV Wiled.
I e o emplo to become subject to the
w rk< r n'C of WATER SYSTE7d/DRFAUNG PAID
O Z wp or
ZO NOTC ,elver .8tw Certifkateof Exemptinkyou NEW RFSDE21MALP B. SQFT. Date Recd tH
sharld mesu ' tothe Workn
e 'Compermrtion provisions of the labor TOTAL:
S N Code,y sur athwith comply witheuch provisions,orthh peret ehal)be BUILDING
] deerned
W p CONSTRUCTION LENDING AGENCY SEISMIC F
CL EE IheabyafRrmthethereb, comtnuctlmlendingager"fortheperfonn ELECTRIC FEE
Z ..of the workfor which twprmit h issued bee 309'/,CN.C) TOTAL: e�
V O lander.Name PLUMBING FEE a-�---
IL lender,Addrt., QTY. MECHANICAL PERMIT FEE iMECHANICAL FEE
O W ladlfy thatl have rtadtw appllotbnaM eatethrtthc above lnformetm
boned.Iagratocomplyw"allcityand muntyoedbunmand elate laws PERMIT NUANCE. FEES PAID.
} N rtleing to building consbudion,and hereby authortre representatNn of this
F Z dty to enter upon the abovcmentbnrd property for Inspection purpcm ALTERORADDTOMECH.
(J _ (We)agree to save,indemrsify an d keep harrdes,the City of Cu xf W Date Recei to
agalvt liabilities,judgments,meeaM eapemes whkh may,In any wayamue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL
tsaid C N cmmequeye�of tFe gnmi�dtw pemdt
1yj`� AIRHANDLINGUNIT(OVER10,000cPM) CONSTRUCTION TAX
Signature of Apphcant/CoJktractor e0ate EXHAUST HOOD(W/DLCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applletnt or futum building oaupent port or handle haraedous HFATWG MIT CEO I Of1,ODO RTL!) Date Recti Ile
rtuterbl as deflred by the Cupertino Muddpl Code,Chapter 9.17,and the
Health and Safety Code Section 2SM(a)7 HATING UNIT(OVER 100,000 BTI!) TOTAL:
E Yes n No.T1'ill the applicant or future building onvpant usecquipment ordevk VPNITLATTON FAN(SINGLE RESID) ISS A •DATE
whkh enet hamedou,air centaMnants as defined by the Ray Area Mr
• Quality Managemem Derrkt7 BOILFR-COMP DEW OR 100,000 Fl Ut NovR ��
Yn No ,r v Qy
have read the hanoos Ar
mrteriab requirements under chapter 6.95of BOILER-COMP(OVM 100,000 BTU) as
the California Health 4 Safety Code,Seetbm 75505,75533 and 75534. I CITY 1 Of
underetand that if the buildingdoes rot curremly have a tenant,that it b my NFWRESTDFNITALMECIL SQ.FT 11 CUPERTINO
nssponsibllity,to notify the occvprt of the mqukmmew whkh ovsat be met
prior to Wuance dfla
a Ct,titmof Occupancy.
Ownn ee awhorlad agent Date ISSUED B
TOTAL
OFFICE COPY